Authorization for Electronic Deposit

Authorization for Electronic Deposit of Vendor PaymentSAS-63

Revised 12/2000

SAS - 63

AUTHORIZATION FOR ELECTRONIC DEPOSIT

OF VENDOR PAYMENT

STATEMENT OF PURPOSE:

To allow state agencies to initiate account transactions to deposit payments directly to a vendor in payment of goods or services purchased. Payments will be deposited directly into the vendors checking/savings account per the vendors authorization.

Agencies should send blank form to vendor to be completed. The vendor must then return the form to the agency with appropriate vendor signatures. The agency then forwards the form to the Finance Cabinet for establishment.

COMPLETION INSTRUCTIONS:

FIELD NAME / INSTRUCTIONS
Agency/Vendor
Agency Number / Enter the department number of the agency requesting the authorization for electronic deposit.
Vendor Information
FEIN/SSN Number / Enter the vendors nine digit Taxpayer Identification Number (TIN) -- either Federal Employer Identification Number or Social Security Number.
Sfx (Vendor Suffix) / THIS NUMBER TO BE AFFIXED BY FINANCE.
Vendor Name / Enter the personal or business name of the vendor.

TIN Name

/ If the FEIN/SSN (TIN) name is different from the Vendor Name, enter the personal or business name identifying the (TIN) Taxpayer Identification Number holder.
Street / Enter the street name or box number of the vendor.
City, State, Zip / Enter the city, state and zip code of the vendor.
Telephone # / Enter the telephone number where a vendor can be contacted during normal business hours.
Contact / Enter the name or the individual that can be contacted at the indicated telephone number.

Note:MULTIPLE STATE AGENCIES MAY BE ALLOWED TO ELECTRONICALLY SEND FUNDS UNDER THIS AUTHORIZATION.

Section A:Enrollment or Change Authorization:

This section of the form should be completed for new enrollments or

changes in financial institution information.

Financial Institution Information
Enrollment or Change Authorization / Enter in the appropriate space whether the authorization is new or a change.
Select One: 1. New Enrollment
2. Financial Institution or Account Change
Bank Name / Enter the name of the vendors’ financial institution.
Branch or Correspondent Bank / Enter the branch name or major bank or the vendors financial institution, if applicable.
City, State, and Zip / Enter the City, State and Zip Code where the financial institution is located.
Transit/ABA No. / Enter the nine-digit American Banking Association (ABA) identifying number for the financial institution. This number can be obtained from the financial institution or from the check or deposit slip from the account. This number is normally the first nine digits of the electronic coding at the bottom of the check or deposit slip.
Account Number / Enter the vendors account number at the financial institution.
Account Type / Indicate in the appropriate space whether the account is a checking or saving account.
Vendor
Signature/Date / Signature of the vendor or vendor designee and date signed.
FIELD NAME / INSTRUCTIONS
Name Printed / Enter the printed name of the individual signing the authorization.
Job Title / Enter the job title of the individual signing the authorization.

Section B:Cancellation:

This section of the form should be completed to cancel the authorization.

The vendor information and financial institution information blocks

should include enough information to correctly identify the authorization

being canceled.

Vendor
Signature and Date / Signature of the vendor or vendor designee and date signed.
Name Printed / Enter the printed name of the individual signing the authorization.
Job Title / Enter the job title of the individual signing the authorization.

Upon completion, send Form to:

Statewide Accounting Services

Capitol Annex, Room 484

702 Capitol Avenue

Frankfort, KY 40601

Office of the Controller, Statewide Accounting Services1